Health Screening - University of Houston
Health Screening
Application for Admission
Master of Athletic Training Program
Checklist for Applicant
_____ 1. Read the “Core Performance Standards for Admission into the Master of Athletic Training Program per attachment and provide your signature stating that you presented them to your physician (M.D. or D.O.) during your physical examination.
_____ 2. Complete the “Medical History Form”.
_____ 3. Obtain a “Physical Examination” by your physician and have him/her complete the provided form with original signature.
_____ 4. Have your physician complete and sign the “Core Performance Standards for Admission into the Master of Athletic Training Program” signature page after completing your physical examination.
_____ 5. Provide all documentation on TB, MMR, Tetanus and Hepatitis B per attached form.
_____ 6. Sign the “Permission to Review Health Screening Information” form.
Core Performance Standards for
Admission and Progression into the Master of Athletic Training Program
Below are listed the performance standards of the professional Master of Athletic Training Program. You should read these standards carefully and be sure you can comply with them. The Master of Athletic Training Program expects that all applicants for admission possess and demonstrate the skills, attributes and qualities set forth below, with or without reasonable dependence on technology or intermediaries.
Issue Standard Some Examples of Necessary Activities
Critical Thinking Critical thinking ability Identify cause-effect relationships in
sufficient for clinical clinical situations, develop and implement
judgment; sufficient powers athletic training care plans; respond without
of intellect to acquire, assimilate delay to emergency situations.
integrate, apply and evaluate
information and solve problems.
Interpersonal Interpersonal abilities sufficient Establish rapport with patients/clients,
to interact with individuals, colleagues and other health care personnel.
families, and groups from a
variety of social, emotional,
cultural, economic and
intellectual backgrounds.
Communication Communication abilities sufficient Explain treatment procedures, initiate health
for interaction with others in teaching to individual clients, document and verbal and written form. Utilizes interpret athletic training actions and
effective communication skills patient/client responses. Communicate
to interact with patient/client, information accurately and effectively with
peers, and other health care other departments/colleagues/client/families.
personnel of various ages, cultural, Evaluate written orders, care plans and
economic, and intellectual treatment requests.
backgrounds in a variety of settings.
Mobility Physical abilities sufficient to move Move around in the athletic training room,
from room to room, athletic work spaces, treatment areas & administer
sidelines to athletic playing field, cardiopulmonary resuscitation. Lift, move,
lift and position, maneuver in small pos. and transport patients without causing
places, and physical health and harm, undue pain, and discomfort to the
stamina needed to carry out athletic patient or one's self. Transport mobile eq.
training procedures. in timely and cautious manner.
Motor Skills Gross and fine motor abilities Calibrate, use and manipulate equipment
sufficient to provide safe and properly; position patients/clients,
effective athletic training care. manipulate a computer, tape and wrap
bandages; maintain sterility of equipment.
Sensory Sufficient use of the senses Hear emergency signals, auscluatory sounds,
of vision, hearing, touch, and cries for help, perform visual assessments of
smell; to observe, assess, and patients/clients. Observe patient(s/client(s
evaluate effectively (both close responses; perform palpation, functions
at hand and at a distance) in of physical examination and/or those related
the classroom, laboratory, to therapeutic intervention.
and clinical setting.
Behavioral Sufficient motivation, responsibility Adapts to assignment of patient and/or
and flexibility to function in new, clinical/lab area in a manner that allows
ever-changing and stressful students to meet objectives while providing
environments. Adapts appropriately a safe, adequate patient care. Accountable
to ever changing needs of clients. for clinical preparation and independent
study and performs athletic training functions in a safe responsible manner. Ability to recognize the need for further research and respond accordingly based on changes in patient/client status since clinical assignment was made.
Signature Page for
Core Performance Standards for
Admission and Progression into the
Master of Athletic Training Program
APPLICANT COMPLETES
I (Print Your Name) ______________________ have read the Core Performance Standards for Admission and Progression into Master of Athletic Training Program and presented them to my physician.
_____________________ ______
Applicant’s Signature Date
PHYSICIAN COMPLETES
Per my physical examination of (Print Applicant Name)_______________________, I confer that he/she is able to perform the technical/performance standards as I have answered below.
____________________________ _______
Physician Signature Date
Please answer one of the following by placing an “X” in the space provided.
_____ 1. Yes, the applicant can perform the above listed technical/performance standards as described above without reasonable dependence on technology or intermediaries.
_____ 2. No, the applicant cannot perform the listed technical/performance standards as described without using some form of reasonable dependence on technology or intermediaries.
If you checked response #2 then complete the following section:
The following reasonable technological or intermediaries are needed for admission and progression into the Master of Athletic Training Program:
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
5. __________________________________________________________________
(Attach other statements or documents as needed)
Medical History Form
Name:_______________________________ University of Houston Student ID.: __________________
Date of Birth: ________________________ Gender: ________
Have you had or do you currently have any of the following?
Respond by circling yes or no. Explain yes responses on the back of this page. Positive responses do not imply denial of entrance into the Master of Athletic Training Program.
Visual Defects yes no
Hearing Defects yes no
Speech Defects yes no
Cardiac Disease/Disorder yes no
High Blood Pressure yes no
Family History of Cardiac Disease yes no
Tuberculosis, Lung, or Respiratory Problems yes no
Hepatitis, Liver Disease yes no
Sexually Transmitted Disease yes no
Fainting Spells, Epilepsy or Convulsions yes no
Diabetes yes no
Kidney or Bladder Disease yes no
Cancer yes no
Back Injuries yes no
Joint Injuries yes no
Any Previous Surgeries yes no
Immunosuppressive Therapy yes no
Currently Under Chemical Dependency Treatment yes no
Do you Smoke yes no
Do you have Allergies yes no
Do you have any communicable diseases? yes no
Do you have a Disability that would prevent you yes no
from meeting the Core Performance Standards
for the Master of Athletic Training Progam?
I have read the above and declare that I have no injury or illnesses other than as specifically herein noted. Any falsification or misrepresentation will be sufficient grounds for my release from the Master of Athletic Training Program.
Signature________________________________ Date:______________
(Applicant)
Physical Examination Form
Name:________________________________
(Print Applicant’s Name)
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I hereby certify that I have reviewed this patient’s information. I have examined this patient and have found them to be free of communicable diseases. I have reviewed their records and find them current on all required immunizations.
Signature: _____
(Original Signature) Date
Documentation of Vaccination Status and TB Skin Test
TB SKIN TEST
Proof of TB Skin Testing Date: ___________
Attach a copy of entry into applicant’s record at MD office
Vaccination Status
1. Proof of Tetanus Immunization: Date: ___________
Attach on of the following below to provide proof
a. copy of entry into applicant’s record at MD office
b. copy of bill for Tetanus Injection
c. copy of Immunization Record
1. Proof of Rubella Immunization: Date:___________
Attach on of the following below to provide proof
a. copy of entry into applicant’s record at MD office
b. copy of bill for Rubella Injection
c. copy of Immunization Record
2. Proof of Measles Immunization: Date:___________
Attach on of the following below to provide proof
a. copy of entry into applicant’s record at MD office
b. copy of bill for Measles Injection
c. copy of Immunization Record
3. Proof of Mumps Immunization: Date:___________
Attach one of the following below to provide proof:
a. copy of entry into applicant’s record at MD office
b. copy of bill for Mumps injection
c. copy of immunization Record
5. Proof of Hepatitis B Vaccination: or Waiver Date:___________
Attach one of the following below to provide proof:
a. copy of entry into applicant’s record at MD office
b. copy of bill for Hepatitis B injections
c. copy of immunization Record
MANDATORY HEPATITIS B VACCINATION DECLINATION FORM
I understand that due to my occupational exposure to blood or other potentially infectious material. I may be at risk of acquiring the Hepatitis B virus (HBV) infections. I understand that I must either provide evidence of immunization (3 injection series) or sign this waiver releasing the University and clinical agencies from any responsibility should I contract Hepatitis B. I release University of Houston, Master of Athletic Training Program or any agency in which I attend clinical experiences of any responsibility for any consequences of this decision.
University of Houston Student ID #
____________________________________________ ___________
Signature Date
____________________________________________ ___________
Witness Date
Permission to Review Health Screening Information
I (print your name)______________________ give the Director of the Master of Athletic Training Program my permission to review my medical records as required by the Master of Athletic Training Program for purposes of my application for admission and progression into the Master of Athletic Training Program. I am aware that they will be placed in a secured location.
_____________________________ ________
Applicant Signature Date
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